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Glossary of insurance terms
Glossary of insurance terms

The Complete Guide to Out-of-Network Billing Terms for Therapists

Updated over a week ago

Let’s start off with the basics:

In-Network

Your therapist and your insurance sign a contract, and your therapist provides services for a set fee. HMO and EPO plans have in-network benefits only.

Out-of-Network

Think the opposite of in-network. Your provider and insurance plan are strangers, don’t have an agreement, and your provider can set their own fees. PPO, POS, and HDHP plans have both in and out of network benefits.

Now on to the Nitty Gritty:

Deductible

This is what you have to pay out of pocket for health services before your insurance benefits kick in.

Premium

This is what you pay every month for your insurance plan.

Out of Pocket Max/Limit

When you pay with your own money for covered healthcare services you eventually reach a max or limit. Once this is reached your insurance pays for 100 percent of all covered costs for the rest of the year. Things that do count towards this maximum are: deductibles, coinsurance and copayments. Things that don’t count towards this maximum are: plan premiums and out of network care and services.

Copayments

What you are actually paying for your health services. For example if a session is $100 dollars once you pay your deductible your copay is only $20 for the visit.

Coinsurance

Basically, the same as copayments but instead of fixed dollar amount it is the percentage of that amount. For example if a session is $100 dollars you have a coinsurance of 20% after you’ve met your deductible.

Ending with the funner part:

Super-bill and Claims

You create a super-bill to generate a claim that proves to insurance that you actually need these services. Basically, just like you might need to prove to your boss that you’re out sick you bring a doctor’s note (create a super-bill) to justify that you were sick and had to miss a day at work (your claim).

Reimbursement

Our absolute favorite word in this list is reimbursement. Insurance includes reimbursement policies in which you may pay out of pocket for a service but receive money back after submitting a claim. The tricky part is, that plans differ on their reimbursement policies which is why you need to find out what your individual benefits are.


Ok great, you have this awesome list of not so awesome words that you can now semi understand. But realistically you just want to know how much you are actually going to be paying for your health services. For an out of network client here is how to best explain it:

Even though you are seeing a practitioner who doesn’t take health insurance, you may still have benefits that will help you cover the fee. First step: you find out your deductible (ex: $3,000). You pay your provider a full fee (ex: $100) before you meet your deductible. Then, once you meet your deductible, you create super-bill and submit a claim to file for reimbursement.

Depending on your coinsurance (ex: 20%) you will only actually be paying that copay (ex: $20) amount for the session, your insurance reimburses you the rest. Yay you get money back! But hold on- you’ve reached your out of pocket maximum, that means your insurance company pays for all covered services for the rest of the year. Well done!

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